Today's New England Journal of Medicine has a fascinating article on how physicians in a five physician general internal medicine practice spend their day. The practice is a level 3 NCQA-qualified Patient-Centered Medical Home with an electronic health record.
Written by ACP member Richard Baron, the article - which was covered by the Wall Street Journal blog, Washington Post, New York Times, and USA Today - describes and quantifies the work that he and his colleagues do in face-to-face visits with patients, reviewing lab and imaging studies and consultant's reports, communicating the results to patients by email or phone, and other clinically related tasks for the 8440 patients seen by the group.
This table shows the average volume of such activities each day and over the course of a year for each doctor in the group. On average, each physician in the group responded to telephone calls or laboratory results an average of 43.2 times, and reviewed 13.9 consultation reports, 11.1 imaging reports and 19.5 laboratory reports, each day.
Not included in the analysis, according to Dr. Baron, are "some high-volume categories of documents are not reported, largely because they are not carefully indexed. Such documents include administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plans (e.g., disease-management letters), and reports on home care and physical therapy. Although such documents are not reported here, they represent a substantial amount of work in a practice."
Dr. Baron's analysis also doesn't include the considerable amount of time that small primary care practices spend interacting with health insurers. Another recent study found that physicians in primary care practices on average spend 3.5 hours, their clerical staff 35.9 hours, and their RN/MA/LPNs 19.1 hours per week on health plan administrative tasks.
Dr. Baron concludes:
"At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field it is urgent that we understand the actual work of primary care and find ways to support it. Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure."
Dr. Michael Barr, ACP's Vice President of Practice Improvement and Advocacy, echoes his point:
"The resources Dr. Baron's office expends to deliver high quality, patient-centered care are typically not paid for in the current health care system. Patients place a high value on the responsiveness of physicians and their practice teams (see CPI Video). To promote and sustain the type of care that patients desire and physicians want to provide, payment systems much change."
In my view, Dr. Baron's article is a wake-up call to policy-makers. If we are going to ensure that patients have access to high-performing general internal medicine and other primary care practices, we need to develop payment structures and revenue streams sufficient to support the value of the clinical work that falls outside of the face-to-face encounter and the overhead involved. We need to employ team-based models to relieve primary care physicians from some of the clinical work involved that could be handled appropriately by trained non-physician health professionals. We need to streamline and reduce health plan interactions. We need to leverage the functionalities of electronic health records to help primary care practices implement best practices. And we need to ensure that health reform doesn’t impose more unfunded administrative and clinical mandates on primary care clinicians.
Today's questions: How representative is Dr. Baron's group's experience with that of your own practice? Do you agree with his call for "radical change in practice design and payment structure" and if so, what radical change do you think is needed?